Imagine There Was No Stigma to Mental Illness: Dr. Jeffrey Lieberman (Transcript)

Dr. Jeffrey Lieberman – TEDx Talk TRANSCRIPT

I know we’re only just meeting for the first time. But I’d like to ask you a question, and it’s a rather personal question.

How many of you suffer from, or know someone who suffers from, a mental illness? Well, think about it. Your family, your friends, your classmates in school, your colleagues at work.

I’ll bet that virtually everybody knows someone with a mental illness.

Now, maybe I should explain what I mean by mental illness. Commonly thought of conditions like depression, schizophrenia, bipolar, and anxiety disorders, and also intellectual disturbances like autism and learning disabilities and ADHD, and addictions to alcohol and drugs.

All of these conditions affect the same areas of the brain and disturb, by varying degrees, the mental functions of cognition, perception, and emotion regulation.

So we’re not talking about the worried well here or problems in daily living. The World Health Organization has estimated that 20% of the world’s population suffers from mental disorder at some point in their lifetime. That’s one in five people, over 70 million Americans. A billion people worldwide.

So if you do the math, everyone should know someone who suffers from a mental disorder, and the fact that many of us may think we don’t reflects three inconvenient truths: that we lack an understanding and awareness of what mental illness is, that we’re reluctant or ashamed to admit it, and that mental illness is highly stigmatized.

Now, stigma literally means “dishonor” or “disgrace.” It’s the mark of Cain in the Bible. It’s the “A” on the dress of Hester Prynne in “The Scarlet Letter,” and it’s the yellow stars that were emblazoned on the clothing of Jews in Nazi Germany.


Well, to show you how insidious stigma can be, let’s do a little thought exercise.

Imagine that you were invited to celebrate your boss’s 50th birthday party, and you were picked to give the toast. But on the day of the event, you got sick, and you had to cancel.

When you called to cancel, would you prefer to say that you couldn’t come because you had a kidney stone or that you were depressed and suicidal?

Or would you rather say you threw out your back or were having a panic attack? Or would you rather explain that you were having a migraine headache or you were strung out on prescription pain medication?

If you would prefer the former to the latter in each case, you, my friends, are affected by stigma.

Now, I experience stigma every day as a psychiatrist. The profession to which I have dedicated my life is the most denigrated and distrusted of all medical specialties. There’s no anti-cardiology movement that’s trying to stamp out cardiology, and there’s no anti-oncology movement that’s trying to ban cancer treatment.

But there’s a virulent anti-psychiatry movement that claims there’s no such thing as mental illness and wants to eliminate psychiatry.

Now, if we thought of mental illness like we do heart disease, then symptoms like depression would be like chest pain; or anxiety would be like shortness of breath; or psychosis would be like an arrhythmia.

In the former case, symptoms emanate from the brain. In the latter case, they emanate from the heart.

But the brain is infinitely more complicated than the heart, or any other organ in the human body, for that matter. The heart is basically a pump composed of four chambers, a dozen blood vessels, and comprised of two billion muscle cells.

The brain, on the other hand, is a three-pound corrugated mass of tissue composed of over 100 billion neurons, which make over 30 trillion connections and form an intricate array of a myriad number of neural circuits, which simultaneously orchestrate functions as basic and vital as breathing, temperature regulation, hunger, coordinate movement. But also form what your personality is and who you are as a person.

The brain gives rise to consciousness and creativity, and it also houses the human spirit. It’s no wonder that it’s taken us so long to understand the brain and appreciate how it relates to behavior and mental illness.

Now, stigma is not unique to mental illness. We’ve seen it associated with illnesses throughout human history: tuberculosis, leprosy, cancer.

The most dramatic example that I know of is AIDS. In the late 1970s, I was an intern at St. Vincent’s Hospital in the Greenwich Village section of New York City when the first cases of AIDS began to appear.

I remember seeing patients come into the emergency room with terrible infections, and we couldn’t figure out what was wrong with them, and we had no treatments, and they invariably died.

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Now, this by itself would have been enough to stigmatize this illness. But the fact that it was occurring predominantly in discriminated groups, including homosexuals and intravenous drug users, made its victims virtual pariahs.

But then an amazing thing happened. The AIDS Advocacy Group and community aggressively spoke out. They expanded awareness, and they pressured the government to fund research.

And within five years, 1984, two scientists isolated the human immunodeficiency virus, the cause of AIDS. By 1987, AZT was introduced, the first treatment for AIDS.

And now AIDS is like diabetes. It’s a chronic illness but you could live a pretty normal life with treatment. Contrast the outcome of Rock Hudson, who was diagnosed with AIDS in 1984, and he was dead within a year, to Magic Johnson, who was diagnosed with AIDS in 1991, and he’s still alive living a normal life, I saw him on TV the other day, with treatment.

That is the power of science leading to knowledge and awareness and effective treatments. Treatments don’t just eliminate the symptoms of the illness. They also eliminate the prejudice and the stigma.

Now we’re still learning the causes of mental illnesses, but we already have effective treatments which have helped millions of people around the world. In many cases, these eliminate the symptoms of the person’s illness, but in some cases, they actually transform their lives.

Earlier in my career, I treated a young mother named Sarah, and she suffered from panic disorder, which had kept her housebound for 10 years because she was afraid to go out, a condition called agoraphobia.

To start, I had to make house calls and visit her at home, and when she opened the door to her home at our first meeting, I saw before me this woman in a long, black, shapeless tunic with dark glasses and long dark hair. She looked like Morticia from the Addams Family.

I began with exposure therapy and then gradually introduced medication. And within a couple of months, she was able to come to see me in the clinic, but she insisted on sitting next to an open door with her bike perched just outside so she could dash at a moment’s notice.

But within a year, she changed her attire. She was fashionably dressed, cut her hair. She was going out with her husband, socializing with friends, and picking her kids up at school.

When we ended treatment, she came to our last session, and she came up to me and thanked me, and she said, “I feel like I’ve been let out of prison, like I’ve been given my life back.”

Now, not all disorders have good treatments. Witness Alzheimer’s disease and autism, and not all patients respond as well as Sarah does. A particularly difficult condition that psychiatrists treat is called borderline personality disorder. This affects young people and produces extreme mood volatility, self-mutilating behavior, and stormy relationships with people.

The noxious nature of the behavior drives away family and friends, and even psychiatrists are reluctant to treat patients. One such patient that I treated was named Laurie. She was in her early 20s, a waif-like girl with short hair, large glasses, a very fragile demeanor that could explode into volcanic rage and propel her into aggressive or suicidal behavior.

I worked really hard trying to help Laurie control her mood volatility, stop her from these self-destructive acts. But the treatments I used, the medications I tried, had limited effects, and when she dropped out of treatment, I felt I really hadn’t done very much, and I worried about what would happen for her.

So, we don’t have treatments for every disorder. And not all patients respond well. But make no mistake, there is indisputably a world of difference between modern mental health care today and what existed for all human history prior to the latter part of the 20th century.

So I find it particularly ironic that while people suffered from mental disorders throughout human history because of the fact we had no knowledge and limited or no effective treatments, in the 21st century, when we do have treatments, the biggest barriers are lack of awareness, lack of access to care, and stigma.

So, if there were no stigma, we could launch a public health initiative against mental illness, like we’ve done before successfully such as with infectious diseases, with heart disease, with environmental toxins like asbestos, lead, and smoking, and we would begin with two simple strategies.

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The first involves early identification and intervention. And this involves having screening mechanisms in place in primary care settings like family medical clinics, pediatrics offices, obstetrical and gynecologic clinics and offices, and also in schools and in universities, and also in the workplace.

And individuals who were screened for being at risk for, or having symptoms of, a mental disorder, would be referred promptly to a clinic that specialized in providing the array of treatments that would be helpful to their condition.

The goal of this is to get people engaged early, before the illness has effects on their brain, disrupts their lives, and risks them doing something that’d be harmful to themselves or others.

The second strategy would be an approach of providing community-based comprehensive care for people who were already at more advanced stages of the illness and had suffered some disability. This would include medical management, rehabilitative services, and also residential facilities to support people who can’t care for themselves and prevent them from falling through the cracks and ending up on the streets homeless, or in prisons, or sequestered in state mental hospitals.

So we have the means to do this, and this would provide extraordinary changes in people’s lives in many, many ways. People who are depressed, who studies have shown to suffer from symptoms of depression for up to seven years before they get diagnosed and receive treatment, would not have to endure this.

And also at the same time while they’re waiting to be diagnosed and treated, risk the possibility of hurting themselves through suicide attempts or becoming addicted to something through misguided attempts at self-medication.

People who experience trauma from violent crime or accidents or natural disasters would be treated promptly, before they develop symptoms, as they’re treated for their physical injuries, instead of waiting for their symptoms of PTSD to emerge and then having them having to seek treatment.

And for people like the first responders and military personnel, who go into harm’s way routinely as part of their job, there would be preventative and decompression treatments routinely administered, rather than waiting to see who develops symptoms and has to overcome the embarrassment of speaking up and seeking help.

People who are abusing substances would be encouraged and supported, rather than blamed and shamed, to seek detox, rehab, and maintenance treatment before intractable addictions developed.

And one in four women expecting babies would not have to risk experiencing a pre- or post-partum mental condition, but would routinely be treated as part of their pre- and post-natal care and so that they wouldn’t have to potentially endure symptoms, potentially harm themselves, or even, God forbid, infanticide.

And children who have learning disabilities or attentional problems would be identified early in their educational course. And they would not just have remedial education, they would have cognitive training, emotional support so they didn’t become so frustrated at their failure in school that they resorted to anti-social behavior and potentially ended up in prison.

Now, you might be thinking to yourself, “Okay, that sounds good. How much is this going to cost? Can we afford to do all this?”

Well, the reality is that health economists have found that providing this kind of proactive mental healthcare would actually reduce the cost of delivering healthcare and result in enormous savings.

In addition, the families of people with mental illness would be relieved of tremendous emotional stress and also financial burden. We would also have the benefit from the fact that many of the glaring social problems that roil our society would be reduced or eliminated, and I’m speaking here particularly about the mass violent incidents that have increasingly occurred.

Too many of these incidents have been perpetrated by young males, largely, who are mentally ill and manifest their symptoms long before they committed their crime. They acted strangely. They were in emotional distress. They were socially isolated. But nobody reached out to them for help.

Instead, they were shunned, ridiculed, or feared. In some cases, families, friends do reach out to try and get their family members or friends help.

Take the case of Gus Deeds, 24-year-old man with bipolar disorder. His father, Virginia State Senator Creigh Deeds, desperately sought to have his son, who was in the throes of a psychotic episode, hospitalized. But to no avail.

Subsequently, Gus viciously attacked his father and then killed himself. So Senator Deeds is now left with scars on his face and pain in his heart, instead of his son.

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So how can we stop the suffering, the violence, the stigma? We have to begin by recognizing mental illness for what it is, a medical condition that can be treated, like we do physical illness.

If you look around you and you saw somebody next to you who was grimacing in pain or passing out or choking, you would rush up to them or you would ask them, “Is there something wrong, or can I help you?”

But we don’t do this when we see somebody who’s emotionally distressed or acting strangely, or too often intoxicated. But that’s what we need to do. We need to be involved, show our concern, don’t be afraid to ask, make it your business.

What’s the worst that can happen? They say to you indignantly, “Mind your own business”? Or “I’m fine, thank you”?

But the best that can happen is you may be able to get somebody help and alleviate unnecessary suffering and potentially harm to themselves or others.

Now, that will work for those around us, that are close to us, or that we’re with, but to have an effect on the whole population, we need to influence the government and the media, either individually or through advocacy groups.

We have to make them understand that mental illnesses are real medical conditions and that we have effective treatments and these must be made available to people.

I’ve been trying to do this by speaking out publicly, including to audiences like you, and writing articles for the lay public and the media.

When Robin Williams died, I wrote an article about suicide, and I received an email in response that was titled, “Message from a patient from very long ago,” and I’d like to share this with you.

Dear Dr. Lieberman,

Last night I read your article about the suicide of Robin Williams and recognized your name. You probably don’t remember me, but between the ages of 15 and 30, I was severely mentally ill with borderline personality disorder and depression. I made many suicide attempts and was frequently hospitalized.

One of those times I took a large overdose and awoke in the intensive care unit of St. Vincent’s Hospital. You were assigned to be my doctor, and I clearly remember how very much you helped me. You probably didn’t see it that way, as I know I gave you a really hard time with my acting out and self-destructive behavior.

However, eventually, with a lot of treatment, I was able to get myself together. I got married, enrolled in nursing school, and graduated as valedictorian. For the past 22 years I’ve worked in psychiatric hospitals. When I look back at just how mentally ill I was early in my life, I would never have thought it could turn out so well, how very fortunate I feel to have a pretty happy life.

And so I just had to let you know. What I remember most from when I was your patient is that you genuinely seemed to care about me and didn’t judge me. But I suppose the best doctors are always the ones with the most heart.

Signed, Laurie.

So this was the same Laurie that I treated and feared for so long ago. I was thrilled to know that she had recovered and to think that maybe I played some small part in this.

But what really struck me most about her email was the fact that it wasn’t my medical knowledge or my clinical skills that she keenly remembered. It was the fact that I showed compassion for her, and compassion is something that we all can show to people, including those with mental illness.

So while science and medicine continues to pursue the causes and the cures of mental illness, I ask that you join me to find the heart and muster, the will to reach out to all people, particularly people who may show signs of mental illness, to raise awareness of the public, of the government, and of the media to end the stigma of mental illness.

Thank you for listening.


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Resources for Further Reading:

The Real Me: The Stigma Surrounding Depression by Ali Schulte at TEDxYouth@AnnArbor (Transcript)

Surviving with a Mental Illness: Eric Walton (Full Transcript)

There’s no Shame in Taking Care of Your Mental Health: Sangu Delle (Transcript)

Lady Gaga on Sexual Assault & Mental Health Speech (Full Transcript)

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